Can someone check my Nursing Diagnoses, please?

[Little_Bear2013]

Thank you for anyone that helps me & bare with me this is only my 2nd one we've done. The first one, didn't have many instructor marks on it, so I hope I can pull it off again with this one.

Assessment:

Primary medical diagnosis: CHF

Other medical diagnoses: HTN, Obstructive sleep apnea, Hx of mini-strokes / TIA's, COPD with emphysema.

Abnormal Lab data: RBC 5.45, Hbg 16.9, Hct 47.2, K 5.6, Glucose 103, Albumin 3.4, Alkaline Phosphatase 149

EKG: Sinus Rhythm w/ borderline L bundle branch block w/ widened QRS. Pt had 7 beats of V-tach the night before.

CXR: Cardiomegaly & mild central pulmn. congestion with l-basilar atelectasis & stable emphysema.

Vital Signs:

0800: R-arm: 160 / 90, 97.1, 24, 70.

0900: R-arm: 168 / 108

1245: R-arm: 204 / 98 L-arm: 168 / 94

Respiratory:

5L of O2 via NC

Rate = 24

Rhythm = Regular with occasional SOB.

Depth = Deep

Cough = Productive & was grayish yellow.

Breath sounds = Sibilant wheezes in all lobes

O2 Sat = 93%

Has long history of smoking & quit 4 days ago.

Does use accessory muscles on occasion.

Pt requested breathing tx at 0809, 1005, 1230.

Other than that most other things were normal.

Nursing diagnoses:

Decreased Cardiac Output r/t impaired cardiac function

- Supporting data:

1.) EKG results of L-bundle branch block w/ widened QRS.

2.) 7 V-tach beats on 03/20/14

3.) BP readings varied throughout the day.

4.) Alkaline phosphatase was 149

5.) Albumin was 3.4

6.) Pt fatigues very easily

7.) Pt on 5L of N2 via NC

8.) +2 non-pitting edema in ankles

Impaired gas exchange r/t excess fluids in interstitial space of lungs

- Supporting data:

1.) CO2 levels at 33

2.) O2 sat: 93%

3.) Adventitious breath sounds (sibilant wheezes)

4.) COPD w/ emphysema

5.) CXR shows mild pulmonary congestion

6.) Dyspnea / SOB

7.) Deep breathing + pursed lip breathing

8.) Pt requested multiple breathing treatments

9.) Productive cough

Activity Intolerance r/t generalized weakness

- Supporting data

1.) Pt fatigues very easily

2.) Arthritis in knees & back

3.) Respirations increase to about 28-30 when moving positions

Risk for impaired skin integrity r/t presence of edema

- supporting data

1.) Braden scale of 20

2.) Age 74

3.) Obese

4.) Altered circulation

5.) Non-pitting edema +2

6.) Pt only walks short distances

Readiness for enhanced self health management:

- supporting data

1.) Pt said she's trying to stop smoking & stopped 4 days & has been on nicotine patch since she came to ER.

2.) Pt said she does watch her Na+ intake at home

3.) Pt is trying to lose weight.

[Esme12, ASN, BSN, RN]

I think it is well done....she needs some aggressive treatment of her B/P and diuretics for the failure for that is what is plaguing her right now.

DO you need only 3 ND and 2 risk?

I see a few others.

[Little_Bear2013]

Ya she's on LASIX & aldactone for the swelling. I think they upped her LASIX because her potassium went to 5.7 possibly due to the aldactone & upped her lisinopril to 20mg from 10mg.

and our teacher just wants 7 nursing diagnoses all togethe

[Little_Bear2013]

The other one I came up with was risk for falls r/t weakness.

- supporting data:

hx of falls, seizures

pt on ACE inhibitors & lasix

85 morse fall

edema in ankles

Peripheral blindnes in left eye

uses a cane

[Esme12, ASN, BSN, RN]

Good....here are a few I see

Excess Fluid Volume: edema

Impaired physical Mobility: cane SOB

Imbalanced Nutrition: more than body requirements obesity

Ineffective Health Maintenance : still smoking